Everyone Is Rational

Clark (not his real name) came to see me complaining of substernal chest pain. At first, he said, it had come on only with exertion, but in the last two weeks it had begun to bother him at rest. It radiated to his jaw and was associated with some mild nausea and sweating. He’d been a pack-a-day smoker for 35 years, had hypertension and diabetes, and a family history of premature heart disease.

Alarmed, I told him this was without a doubt unstable angina and that he needed to be admitted to the hospital for a cardiac catheterization. He asked me what that entailed. I explained that a cardiologist would insert a catheter into his groin and thread it up his aorta until the tip of it was positioned at the openings of his coronary arteries. Then he would squirt intravenous contrast into them to see where and how extensive the blockages in his heart were. He would then perform an angioplasty or place a stent or—if the extent of disease was severe enough—pull out without any intervention and recommend a coronary bypass operation. It all depended on what he found. Afterward, Clark would have to lie flat on his back for six hours with a sandbag on his groin to ensure the catheter puncture site clotted over properly.

I told Clark that few circumstances existed in medicine in which the choice confronting a patient was as black and white as this one: if he didn’t have this procedure he would almost certainly suffer a heart attack at some point and possibly die.

To my great surprise, he refused. Did he understand, I repeated, that he could die? Yes, he said, he did. Why then, I asked, was he refusing the procedure? He looked at me somewhat sheepishly. Then after several moments, he finally blurted out, “I don’t want anyone looking at my groin.”

I was stunned. “Why?”

“I’d rather not say,” he told me.

IRRATIONAL ON THE OUTSIDE, RATIONAL ON THE INSIDE

“That makes no sense.” How many times a day do we find ourselves thinking that about other people’s behavior? Perhaps someone decides to refuse an offer to come to the head of a line; or chooses to spend more money for a brand name when the generic is identical in every way; or refuses a potentially life-saving procedure he desperately needs. But no one ever does anything without a reason that makes excellent sense—tothem. Even when the reason is completely divorced from reality, as in schizophrenia, the thought process that flows from that first idea will usually be logical and sound. Once you accept that the F.B.I is listening in on your conversations through the radio receiver in your dental fillings, being wary of strangers and worrying you might be arrested both become eminently reasonable and entirely rational.

Unless the behavior we’re examining occurs as a result of a true derangement of normal brain functioning, as occurs after a concussion or due to delirium, we err when we label anyone’s behavior “irrational.” Even demented patients think rationally and logically (until their ability to think is completely destroyed). I once had a patient complain to me that people were coming in during the night and rearranging his possessions. His son insisted to him this was impossible, that the doors were always locked, and that it made no rational sense for anyone to do that. The answer to the riddle turned out to be that he was suffering from advanced dementia and simply didn’t remember that he was moving his things himself. As he had no memory of even forgetting, he’d arrived at the entirely logical conclusion (to him) that someone else was doing it.

But even if behavior is only rarely genuinely irrational, it certainly is often foolish. People do frequently act in ways that take them farther from their goals, either because they mistakenly believe their action will bring them closer or because they find themselves compelled by another goal they mistakenly believe is more important to them.

HOW TO APPROACH “IRRATIONAL” BEHAVIOR

I could have dismissed Clark’s choice as irrational and left him at the mercy of its consequences. In fact, in other circumstances, with other patients, I’ve have. For example, my Jehovah’s Witness patients believe receiving the blood of others into their bodies is a mortal sin, literally akin to murder. I’ve had some of them refuse blood transfusions even in the face of potentially life-threatening gastrointestinal bleeding. When a Jehovah’s Witness does accept a blood transfusion (as I once observed when two parents broke down and allowed a life-saving transfusion to be performed on their 10-year-old son), they’re often ostracized from their community and become pariahs. Colleagues of mine have made disparaging comments about this kind of behavior, labeling it irrational, but all I had to do was once ask a Jehovah’s Witness why their group refused blood to understand the choice wasn’t irrational at all. Foolish, you could certainly argue, but not irrational.

The difference ends up being more than just a splitting of hairs. Labeling someone’s choice “irrational” blocks the impulse of others to understand it. And what we don’t understand we tend to either fear, ignore, or both. And if you don’t first understand why a person is making a certain choice, you’ll have no chance to change his mind when changing his mind seems the most compassionate thing to do.

“I respect your right to make this decision,” I told Clark, “even though I believe it’s not in your best interest. But I really do care about what happens to you, so I’d really like to know why it’s so important that no one sees your groin.”

He could tell I wasn’t going to let it go. He sighed. Then in halting tones he answered, “I only have one testicle.”

I knew this, of course. As a child he’d been cryptorchid—that is, one testicle had simply failed to develop. I looked at him with sudden understanding. “You’re embarrassed—”

“I know I’m being ridiculous,” he admitted. “But maybe there are medicines you can use to treat my heart with instead…?”

Unfortunately, I told him, without knowing his coronary anatomy I had no way to know which treatment was best. He understood, but I could see he felt horribly trapped. It turned out not only was he desperately afraid of dying of a heart attack, he recognized his reason for refusing the procedure was foolish, which only embarrassed him further.

“You know that everyone involved in the procedure is a medical professional,” I reminded him. He nodded.

“If you were missing a portion of your lung,” I argued, “would you be embarrassed about getting a chest x-ray?”

“No.”

“Why not?”

“Because…because…I don’t know…”

I studied him for a minute. Then I ventured, “Maybe because your lungs have nothing to do with your manhood…?”

His expression grew pained. Then he nodded. “You must think I’m being ridiculous. At my age.”

“No,” I replied. “I completely understand. We’re not in charge of how we feel about a lot of things.” I paused. “All I can think to tell you is that manhood, in my view, has nothing to do with anatomy. It has to do with your character. With doing what’s hard because it’s best.”

Clark didn’t agree to having the catheterization that day. I told him to think about it, knowing a tincture of time is often what people most need to be able to adjust their thinking.

Which, in fact, he did. A week later he called me to tell me he wanted to go ahead with it, and he had it done the next day. We found what in medicine we call a “widowmaker” lesion—a 90% blockage of his left main coronary artery, which bought him a bypass operation the day after that.

Several months later he returned to my office for a follow up. He still felt embarrassed that he’d almost put his ego before his health, he said with a laugh, but that otherwise he was feeling fine. I told him I was glad his ego had listened to reason.

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I look forward to ending my Sunday evenings reading your latest post. It allows me to end my weekend and begin my week in a meditative, mindful frame of mind. I have never written before to tell you how much your posts have meant to me. This one particularly struck me as I struggle with the political views of my brother and his son. Most conversations with either of them end with me wondering how anyone in their right mind could believe what they believe. (What is probably what they think of me.) This article has made me think about the arrogance of that point of view and that, however painful, I’ve got to understand the how, in their world view, their beliefs are rational, before I can enter into real conversation with them.

Paul: Thank you so much for taking the time to comment. You grasped the point of the post exactly. How can we have a real dialogue with others unless we’re willing to try to understand their point of view first, even if we ultimately reject it? Dialogue is the key to peace, whether between individuals or nations.

Thank you for this post. I have Asperger’s Syndrome and it can be hard to explain the reasons for my behaviour to people. I think this will help me because it’s a way into an explanation. My logic does not always resemble your earth logic…!!

Alex, this is a very timely article for me. Not the testicle concern but the succinct description of the angiogram. I suspect that my cardiologist will schedule me for one following the results of recent diagnostic tests. I just wish he would be as direct and clear on the potential course of action as you were with your patient. In my case I have to do my own research and then have him reluctantly confirm or correct my interpretation of the potential alternatives. Your approach is much better and factually reduces patient anxiety. Good for you and your fortunate patients!

Hi, Alex. It strikes me that what you are examining here isn’t rationality so much as emotional consistency. What Clark had to reconcile were two desires that his medical condition placed in conflict with each other: to avoid shame and to live. What if he had clung to his decision not to have the cardiac catheterization on the grounds of shame? Would you still call his thinking rational? People make decisions like this all the time, although perhaps less so in life and death situations?

It seems to me that most people are, in fact, irrational, making decisions based on feelings (like shame or fear) because they lack either a compassionate and patient interlocutor like you who can point out the specific facts underlying their feelings or the courage to face those facts (I was about to throw my life away over my feelings about my masculinity). Politics gives us this sort of behavior writ large. (Eliot Spitzer comes to mind as a particularly egregious example of this irrationality, but some would argue going to war when we didn’t have to is a far worse one in terms of its consequences.)

Of course we probably have to agree on what we mean by rational, which will get us into really sticky territory. To the extent rational refers to reason, it implies an element of sound judgment. Sometimes rational can also be used to refer merely to logical conclusions from absurd premises. But even when we agree that to be rational should include an element of good sense, we are likely to run up against the question of whose notion of good sense we use to judge whether a person is rational.

You and I agree, however, on the need to ask questions, to “unpack the position” before coming to any conclusions about whether it is reasonable.

Wishing you and your family a happy Thanksgiving!

rdp: Excellent points, all. In my view, irrational would have been Clark refusing the catheterization when he really wanted to have it because he would then have been acting counter to his own most pressing desire, i.e, to live. Had he himself told me his vanity was truly more important to him than his life, though I would have considered that foolish, I would have understood his choice in the context of his values and wouldn’t have labeled it irrational. My point wasn’t so much that people don’t behave irrationally as it was that we tend to incorrectly label behavior as irrational that doesn’t conform to our own values. I agree that we often feel competing desires and have to choose between them. The question of who or what does the choosing and therefore ultimately arbitrates within us which desires are more important than others is fascinating and far beyond the scope of my little post.

Yes, I agree with you that we use “irrational” as a lazy way to dismiss other people’s viewpoints. It saves us the trouble (and potential discomfort) of interrogating our own views as carefully! This topic is actually, in a way, tangential to the one of bullying on which you posted earlier. Or I see it as such, anyway. It seems to me the biggest obstacle to people’s acting in their own rational self-interest is the absence of gentle wisdom from outside (your role vis a vis Clark) and the openness to receive it. Without those two things it is often hard or impossible even to pick out one’s true feelings and values from defensiveness and rationalizations. It is the rare person, in my experience, who is able to say, for instance, my vanity is more important than my life. Most would simply refuse to bring the two desires into the same frame.

rdp: I couldn’t agree more. Which is one of the reasons I view the acquisition of wisdom as the most important goal any of us could ever embrace.

After 50-plus years in pursuit of “foolishly rational” goals and having both suffered and inflicted the life wounds of such choices, I am belatedly seeking the kind of balance I find in your posts.

Thank you for taking the time and effort to share the routes to balance that you have found.

Richard: Though I know nothing about the details of your life or goals I would still say to you, as a statement of fact, that it is never impossible to change the direction of even a 50-plus year-old life in one instant. As you never know when that instant will arrive, never give up! Wishing you the very best of luck and unlimited strength of resolve.

I also work in the medical field. One of the best books I read was “The Spirit Catches You and you Fall Down”—it’s a long version of your post. I re-read it every 3-4 years to remind myself to think outside my own reasoning.

Kristen: I’ve heard of the book but have never read it. I’ll put it on my list. Thanks for the comment.

Thank you for this profound insight into the human psyche. This link was sent to me by a friend, and it is my first experience of reading you. This is what the outcome always is, a happy one, when we work from a state of love for our bretheren rather than limit ourselves to clinical and bookish knowledge!

I pray that may every Clark receive the love and expert care of an Alex! God Bless!

Given some of the recent data comparing intervention vs intense pharmacological care, I’m starting to wonder if that decision is as black and white anymore. CABG may have some advantages but I question to utility of stents in primary prevention. It seems symptomatic relief is their main benefit.

Isaac: You’re absolutely right to wonder about the effectiveness of stents compared to medications for many types of coronary lesions. Mortality end-points in most populations seem to be about equal (and, in fact, have been shown as such for almost a decade). However, a left main lesion, especially in a diabetic, is still black and white: you need a bypass.

Alex, I’m touched by your skillful handling of your patient’s health crisis. But I’m also touched by your ability to respect other people’s (non-violent) religious beliefs (I’m referring to the Jehovah’s Witnesses). Too many people are inclined to dismiss their ideas as “primitive,” “cultish,” and “irrational.” Your respect is another form of compassion.